The nurse assesses a client admitted with advanced cirrhosis of the liver. Which laboratory results are consistent with the disease process? Select all that apply.

Albumin 7.2 g/dL (3.5-5g/dL)

Platelets 75,000 cells/mm3 (150.000-400,000 cells/mm3)

Amylase 200 units/L (30-220 units/L)

Ammonia 96 mcg/dL (10-80 mcg/dL)

Prothrombin time 22 seconds (11-12.5 seconds)

Answer and Explanation

Correct Answer : B,D,E

Rationale:

A. In advanced cirrhosis, the liver’s synthetic function is impaired, leading to decreased production of albumin. Low albumin contributes to ascites, peripheral edema, and decreased oncotic pressure. A value of 7.2 g/dL is well above the normal range and is inconsistent with cirrhosis, making this an unlikely finding in this disease process.

B. Thrombocytopenia is a common finding in cirrhosis due to multiple mechanisms. Portal hypertension causes splenic enlargement (splenomegaly) and sequestration of platelets, while impaired liver function decreases thrombopoietin production, reducing platelet formation. A platelet count of 75,000 cells/mm³ reflects significant reduction and is consistent with advanced liver disease.

C. Amylase is an enzyme produced primarily by the pancreas and salivary glands. While levels may be slightly elevated in pancreatic disorders, it is not a specific or consistent marker of liver dysfunction. A value of 200 units/L is within or near the normal range and does not correlate with cirrhosis.

D. Elevated ammonia occurs in cirrhosis because the damaged liver cannot efficiently convert ammonia to urea, leading to accumulation in the blood. High ammonia levels are associated with hepatic encephalopathy, causing confusion, altered mental status, and other neurologic symptoms. A value of 96 mcg/dL is above the normal range and consistent with advanced liver disease.

E. The liver synthesizes most clotting factors, so impaired hepatic function in cirrhosis leads to coagulopathy, reflected as a prolonged prothrombin time (PT). A PT of 22 seconds indicates significant impairment of the clotting cascade, which is a common complication of advanced cirrhosis.

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Correct Answer is C

Explanation

Rationale:

A. Obtaining a type and crossmatch is necessary for blood transfusion in variceal bleeding, but this is not the immediate first action. Stabilizing the airway takes precedence over preparing for transfusion.

B. Inserting two large-bore IV lines is important for rapid fluid or blood replacement, but it comes after ensuring the airway is clear and the client can oxygenate effectively. IV access alone does not prevent hypoxia.

C. Suctioning the airway is the first priority. Clients with variceal bleeding are at risk for vomiting large amounts of blood, which can obstruct the airway and cause aspiration or hypoxemia. According to the ABC (Airway, Breathing, Circulation) priority framework, maintaining a patent airway is always the first action in emergencies.

D. Preparing the client for endoscopy is essential for definitive treatment of variceal bleeding, but this is not the immediate priority. The client must first be stabilized—airway maintained, breathing supported, and circulation ensured—before diagnostic or therapeutic procedures.

A. Heart rate: 92/min B. Respiratory rate: 20/min C. BP: 122/58 mm Hg D. Oxygen saturation: 96% on room air E. Client rates pain as 3 on a 0 to 10 pain scale F. Bowel sounds hypoactive in all four quadrants. G. Client vomiting brown liquid and reports continuing nausea. H. Urinating without difficulty, urine is clear yellow.

Correct Answer is ["A","B","D","E","H"]

Explanation

Correct Answers

Heart rate: 92/min is correct because this reflects improvement from the previous tachycardia of 109/min, indicating stabilization of the client’s hemodynamic status.
Respiratory rate: 20/min is correct because this shows improvement from the previous tachypnea of 26/min, indicating better respiratory function and decreased distress.
BP: 122/58 mm Hg is incorrect because the blood pressure remains unchanged from Day 1. While it is stable, it does not specifically demonstrate improvement.
Oxygen saturation: 96% on room air is correct because this is an improvement from 93% and indicates better oxygenation and respiratory status.
Client rates pain as 3 on a 0 to 10 pain scale is correct because pain has decreased from 8 to 3 following medication administration, indicating effective pain management and clinical improvement.
Bowel sounds hypoactive in all four quadrants is incorrect because hypoactive bowel sounds continue to reflect decreased gastrointestinal motility and do not demonstrate improvement.
Client vomiting brown liquid and reports continuing nausea is incorrect because ongoing vomiting and nausea indicate continued gastrointestinal irritation and do not represent progression.
Urinating without difficulty, urine is clear yellow is correct because adequate urine output and normal urine characteristics indicate improved hydration and renal perfusion.

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The nurse assesses a client admitted with advanced cirrhosis of the liver. Which laboratory results are consistent with the disease process? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse cares for a client with cirrhosis who is experiencing variceal bleeding. What should the nurse do first?

Correct Answer is C

Explanation

Correct Answer is ["A","B","D","E","H"]

Explanation

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